Using Your Head

If there’s a general truth in the “Everyone’s unique” world of seating & positioning, it might be this: Nothing is necessarily as it seems.

In a simpler world, if a client’s head were laterally flexed or rotated, the answer would be “Just reposition his head!” But in reality, headpositioning problems might stem from issues with the pelvis, the lower extremities or the upper extremities.

That’s just one of the many challenges facing clinicians and ATPs seeking to provide their clients with optimal head positioning.

Our first question: During a seating assessment, what are some indications that a client might have difficulty with head positioning?

All four experts indicated that even when a client’s head is not positioned optimally, the ultimate cause might lie elsewhere.

“If head positioning issues present, be careful to not start there, but first assess the whole person and the seating,” Lise Desharnais says. She adds that there is a wide range of indications for head positioning difficulties, including “tonic neck reflex issues, scoliosis/kyphosis, passive ranges of motion at the neck, weakness, drooling, swallowing and eating disorders.”

Jay Doherty says his assessment begins as soon as he sees a client.

“I start looking at them the moment I lay eyes on them,” he says, “even if they’re transferring out of the car. You notice how they use their bodies — pelvis, lower extremities, trunk, head and neck, upper extremities. Do they move their head around, or does their head stay in a very similar position as they move? As they’re transferring, does the care provider support their head, or do they reposition their head a certain way during that transfer?”

It’s important to note such details and notice how other parts of the body are positioned — in part because even clients and caregivers might not be aware of how poor positioning elsewhere can affect head positioning.

“Oftentimes clients and/or caregivers will report that the headrest is not mounted properly, does not fit, or simply is not working, and request adjustments or an alternative headrest,” Angie Kiger notes. “However, the actual issue is related to how the client is positioned in his/her seating system.”

“You start with the hips,” Gabriel Romero says. “But I find out that a lot of the times, I can tell what the hips are doing by the head positioning. And I can see if there are already some deformities or things that are happening based on how somebody’s head is positioned. Not only that, but I’ve seen some people positioned perfectly — the old ‘90°, 90°, 90°’ rule — who still had really poor head positioning because of a lot of variable factors, from diagnosis to fatigue.”

Common Diagnoses, Common Impacts

Making head positioning even more complex is the wide range of diagnoses that can contribute to the problem.

Poor head positioning can also threaten a wheelchair user’s ability to remain independently mobile.

“Another area to consider when discussing the impact of head positioning and support is access to power wheelchair input devices such as head array, chin control, and sip & puff ,” Kiger says. “If the client’s head is not positioned well, he may not be able to independently control his power wheelchair or other technology devices.”

In addition, poor head positioning can cause its own array of physical challenges. In addition to the swallowing and eating problems that Desharnais mentioned, Doherty says, “Is it aff ecting their breathing? Do they have a harder time speaking? It may be the volume of their speech that’s impacted, or the quality of their speech. Visual field is going to be impacted.”

Clients with poor head positioning may also have difficulty righting themselves if they begin to lean to one side.

“If you and I are leaning,” Doherty explains, “we can bring ourselves back to that centered position again. But someone with their head off to the side may have difficulty… Their center may not necessarily be the same as our center.”

And Doherty adds that head positioning may even impact how wheelchair users are perceived by others.

“If someone has a head positioning issue, the perception of others may change in a negative manner,” he says. “They look like they have a greater disability than they do because their head positioning is not optimal. So certainly there’s a social aspect to it.”

What Are the Rehab Team’s Goals?

Every seating & mobility client presents uniquely, and different clients have different goals. So do their rehab teams.

Desharnais says, “The head support has to be integrated to the whole seating system. In the end though, I try to accommodate fixed spinal deformities — for example, to have the head as level and functional as possible. It is all about the head, and really the eyes. So, if there is a flexion deformity of the spine and neck, one may need to slide forward on the seat and slouch to get the head upright. Same with lateral curvatures: Aim to have a level gaze.”

While some clients do well with equipment that just supports their heads, Romero says other clients may want to work on strengthening their muscles to improve head positioning over time.

“When you’re looking at the therapy behind [head] positioning, a lot of times we say we have somebody that has fatiguing issues,” he says. “So we’ll just create a barrier instead of saying, ‘How can we use therapy on our side, and remove that barrier so they can gain some strength?’ You have kids with cerebral palsy that can gain that strength, and you want to be able to allow them to achieve that instead of creating a barrier.”

Talking to all members of the rehab team can help everyone to understand and consolidate goals.

“The client’s speech-language pathologist, respiratory therapist, nurse, recreation therapist, physician, etc., may be able to provide vital information regarding the impact of head positioning as it relates to activities such as feeding, vocal quality, communication, cardiopulmonary status, participation in leisure activities, vision, hearing, behavior, and any other vital input for a specific client,” Kiger says. “Remember that during the seating evaluation you are only seeing the client for a snap shot in time, so lean on other team members to help you gain a clearer picture of the client.”

The Size of a Fingertip

Our heads can move in many directions, and that’s part of the headpositioning challenge.

“Your head moves in almost every plane of motion we have,” Doherty says. “The top of your spine is around the size of the tip of your finger, maybe a little larger. You’ve got a head that can be eight to 10 lbs., and it’s balanced on that point. All those muscles have to be working exactly right and together to balance the head and allow it to move. That’s a lot of weight to manage on that one little point.”

So how can ATPs assess how well that management and muscle balance is working?

“Assess using your hand,” Desharnais says, “Where and how much force is needed to position the head? Consider size and shape of the head.”

“Prior to determining if head positioning is an issue for a client, it is important to ensure that the client’s pelvis, trunk, and lower extremities are properly positioned,” Kiger says. “Once the rest of the client’s body is in the most optimal position, it is important to next look at how his/her head is positioned. If the client is not able to maintain his head in neutral while sitting, take note as to which direction the client’s head tends to fall. During the seating assessment, it may be a good idea to use your hands to attempt to position the client’s head in the optimal position for him. By using your hands you are able to determine how much active movement the client has, if there is tightness in a certain area, the direction of the force and the amount of force needed to correct it, and the amount of support needed in terms of surface area.”

Romero agrees that other parts of the body can cause positioning problems that aff ect, but aren’t ultimately caused by, the head. For instance, many clients with head-positioning issues have poorly positioned upper extremities as well.

“What’ll end up happening is the arms pull them in directions, and the head will end up following,” he says. “All the head needs is just a breath of wind to push it over. If you have an armrest that’s a little lower than the other, that’s the side that the head will be on.

“I’ve seen sometimes where the pelvis is fine — it’s positioned properly, but a lateral on the side that the head was leaning to was out a little And all we needed to do was adjust the lateral in a little bit to keep the client more midline, which was helping the head stay midline.”

What Does Success Look Like?

For instance, Doherty says, “A little bit of tilt or recline can go a long way to help with head positioning. They can manage their head position a little bit better throughout the day by allowing gravity to help them keep their head upright. I always tell people you have to be careful of how much tilt you provide because we have a righting reaction, and because of that, the person could end up with more of a forward head position. So I usually don’t go past 10° on average. When you go past 10°, that’s a little further back, and a lot of people have a tendency to flex their heads forward to see where they’re going. You don’t want orthopedic changes to happen over time. I may tell them, ‘While you’re driving, tilt 5° or 10° if that allows you to hold your head up better. Then when you get to where you’re going, tilt back a little bit further, put your head back on the headrest, and relax.”

Of course, many clients also can benefit from head-positioning components — though getting clients to buy into a hardware solution can be tricky.

Romero says, “There are some people that don’t want something to look aggressive, but they still need positioning. I’ve had some adults say about a system, ‘Oh, this is too much,’ but it’s really what they need.”

With ALS clients, for instance, Romero says the rehab team has to help the family understand “the way they are now is not the way they’re going to be in weeks’ or months’ time. You show an ALS client [a more aggressive system] and they say, ‘No, no, no.’ But if you can show them a system that looks really clean, they may buy into that a little bit more.”

To deal with the complexities of achieving the right positioning, Romero says adjustability is key. “It’s important to have attaching hardware to the headrest pad that has a ball that you can rotate at any angle,” he explains.

Kiger adds that considering a range of components and options can also help to solve tough positioning challenges.

“There are also components such as facial pads that come in a variety of shapes and sizes and can be added onto headrests, and different types of headrest covers,” she notes. “Another key piece to the proper head support selection puzzle is mounting hardware — not only of the actual headrest, but also of the additional components. It is important to determine how much adjustability of the mount is needed for optimal positioning of the headrest, and how the mount will be attached to the chair. For example, if a client puts a great deal of force to the right side of the headrest, it might be worth considering off setting the hardware from midline to the right to absorb the force at a more direct angle.”

At the same time, Desharnais says, achieving a balance between technology and appearance is also crucial.

“Consider aesthetics and how others may perceive the head support,” she says. “Decrease bulk, and only use surfaces that are doing something.”

“You want the equipment to fit the person,” Doherty says. If you’ve got a huge, wide headrest, you have to stop and ask, ‘What’s my purpose for it?’ And if there is a real, functional, positional purpose to it, then OK. But if there’s not — I’m a believer that less can be better sometimes.”

Aiming for Long-Term Improvement

Romero says younger children can sometimes show amazingly quick and dramatic improvements in head positioning once the seating team has incorporated solutions: “It’s like magic,” he says.

But much of the time, seeing real improvement is a slower process, he admits. “With some of these individuals, you’re only going to get an quarter of an inch or an eighth of an inch at a time when it comes to bringing them back to neutral. I’m talking about individuals where their ears are touching their shoulders, and that’s their positioning because they never had cervical stability. You can’t have 100-percent correction because of what’s happening with the neck muscles being extended or retracted. At times, you have seconds’ worth of rotation instead of minutes. You’re just looking for that minimal stuff : ‘OK, I was able to get an eighth-inch up, so I’m stopping gravity now.’”

Even if some improvement is visible right away, Doherty says tracking a client’s progress is important.

“Sometimes success is them going home and you following up with them and hearing, ‘Hey, I can hold my head up all day long now!’ Sometimes you don’t necessarily know it at the appointment because maybe we were reducing fatigue. If it’s positionally, it’s a little easier to see sometimes because if they can achieve a more centered head alignment, we can physically see the change. But sometimes it’s waiting and seeing — is the person finding it easier to do certain activities now? Is the person finding classes easier now because they’re not working so hard to hold their head up anymore? Can they see the board the whole time they’re in the classroom now?”

Kiger says, “The best way to determine if you have succeeded in creating the ideal head positioning system for a client is to work with the client and his team to monitor the client over time. If the client and/or team report that the client is happy, comfortable, does not exhibit any negative impacts from the system (e.g., respiratory issues, difficulty with swallowing, pain, injury, skin breakdown, etc.), is safe, is functional while using the headrest, and the caregivers are able to effectively utilize the equipment, then it is likely that you have helped your client obtain the optimal head support system.”

This article originally appeared in the June 2013 issue of Mobility Management.